Systematic Approach for Management and Prevention of Boxy Breast.

BACKGROUND: Although a boxy breast is a common aesthetic problem following breast reduction and mastopexy, literature regarding this deformity is scarce. It is vaguely described as a definitive postreduction deformity. To address this complication, it is important to fully analyze the problem, understand and predict its causes, and then try to prevent it.
METHODS: This study included two groups. Group 1 included 14 patients presenting with boxy postoperative breasts. Revision surgeries were conducted for all patients, and the first algorithm was created for quantifying breast surgery in revision cases. Group 2 included 37 cases of primary mammaplasty reduction/mastopexy performed between 2016 and 2019. All the patients in this group were treated as per the study algorithm.
RESULTS: Patient satisfaction was measured on a scale of one to 10, with one being extremely dissatisfied and 10 being extremely satisfied. The results indicated overall satisfaction, with average scores of 9.5 and 9.1 in groups 1 and 2, respectively; the scores of surgeon satisfaction were 8.2 and 8.6, respectively.
CONCLUSIONS: The proposed algorithm, preoperative markings, intraoperative techniques, and postoperative orientation may help achieve optimal results and prevent undesired deformities or asymmetry. Applying a flexible and simplified algorithm provided a more objective plan, which enabled surgeons to attain more satisfactory results. Following a preset quantified plan supported and shortened learning curves and objectively addressed the common postoperative complication, breast boxing.

INTRODUCTION

Breast reduction and mastopexy are amongst the most common procedures performed by plastic surgeons worldwide. The physical, psychological, and emotional benefits of aesthetic breast surgery are attributed to the high number of breast surgical procedures. Nevertheless, this has given rise to various complications that require surgical correction; unfortunately, these procedures have the highest total combined share in surgical malpractice claims.[1]

Although a boxy breast is a common aesthetic problem following reduction mammaplasty and breast lift surgeries, literature regarding this deformity is considerably limited. Furthermore, literature describing a definitive postreduction deformity is vague.

In 2005, Hidalgo was the first to objectively describe aesthetic complications of vertical mammaplasty and deformities involving the lower pole.[2] The boxy shape was attributed to either excessive glandular tissue lateral to the pillars, or excess skin in the horizontal direction. Subsequently in 2013, Tebbetts described two common deformities that develop after reduction mammaplasty based on the nipple to inframammary fold distance, namely boxy and bottoming breasts.[3]

Throughout the last decade, several studies have attempted to apply measurements to ensure that breast surgery employs more quantifiable techniques. Blondeel et al divided the breast into three major components: the conus, skin envelope, and footprint.[4] Mallucci and Tebbetts then described the nipple to inframammary fold (N/IMF) aesthetic distance. Mallucci related the distance to the breast vertical height, whereas Tebbetts used breast width as a reference to the N/IMF distance.[3,5,6] Tebbetts also applied an algorithm for skin envelope design based on the vertical skin excess, allowing better fitting of the skin envelop to the inside conus. This greatly minimized contour problems usually faced after reduction or mastopexy.[3,6,7]

To tackle boxing problems after reduction or mastopexy, it is important to fully analyze the problem itself, understand and predict its leading factors, and then attempt to avoid it. Additionally, a clear understanding of breast aesthetics, especially those of the lower pole will serve to understand and prevent its occurrence.

This study used previously described quantitative and qualitative measurements to develop a comprehensive step-by-step algorithm that may help surgeons to objectively optimize postoperative results. This will ultimately prevent development of the boxy breast appearance after primary reduction/mastopexy. In revision cases presenting with boxy breasts, the study aimed to provide an objective approach for analyzing the problem and managing the case accordingly.

METHODS

The study was performed between December 2016 and November 2019; 57 patients who were candidates for reduction mammaplasty, mastopexy, or revision mammaplasty after reduction or mastopexy with boxy breasts, were included. Fifty-one patients were followed up for 6 months. The patients’ ages ranged from 30 to 59 years, and all individuals provided a detailed history, underwent full breast examination, and received detailed information regarding the study. Each patient signed an informed consent form for participating in the study and for publication of their photographs for educational purposes. The study protocol was approved by the Ethics Committee of the Faculty of Medicine, Cairo University.

Patients with a body mass index of >33 kg/m2, postbariatric breasts, congenital contour deformities, or with a history of oncoplastic surgery were excluded from the study. All patients were photographed in standard views, preoperatively and up to 12 months postoperatively.

Study Design

The study patients were divided into two groups. According to Blondeel system for assessment of the breast and Tebbets formula for calculating the aesthetic N-IMF distance, an algorithm was suggested for analysis and management of boxy breast problem in group 1, and prevention of the problem in group 2.

Group 1

This group included 14 patients; all were seeking revision surgery for boxy breasts after reduction mammaplasty or mastopexy and were referred from other centers. This study was conducted between 2016 and 2019 to analyze this complication. Problem analysis was conducted on all patients; the first algorithm was created accordingly for revision procedures, depending on whether the skin component and/or the conus was being targeted.

Their management included skin management via simple elliptical excision of the vertical limb, lipomodelling (lipofilling of the central portion and/or liposuction of the lateral breast), recreation of breast pillars, and even total revisional mammaplasty.

Group 2

This group included 37 women seeking reduction mammaplasty or mastopexy between 2017 and 2019. These patients were planned and marked preoperatively following a simple sequential step-by-step algorithm that addresses the skin envelope design according to the measurements suggested by Tebbetts; the algorithm was modified so that the horizontal skin excess was tailored according to the available parenchyma. Surgery was performed considering the pillars concept and lateral breast lipo-contouring.[3,6]

For descriptive purposes, the management plan for group 2 has been addressed first.

Primary Cases (Group 2)

Preoperative Analysis and Markings:

Essential lines were drawn; these included the midline, inframammary line, breast upper border (take off) line, and vertical and transverse meridia. The following measurements were then taken: suprasternal notch to nipple, nipple to inframammary fold, and breast width. Examination of the breast included evaluation of skin tone, parenchymal consistency and amount, and manual palpation for possible masses. The new nipple position was then drawn on the meridian at the level of the inframammary fold, according to the point technique proposed by Pitanguy.

The skin envelope excess in either the horizontal or vertical directions was then calculated (Fig. 1).

Fig. 1.

Preoperative markings algorithm in reference to Tebbetts (2013); the markings were upgraded as per the definition of skin excess.

Special concerns (including breast width measurement and the future nipple to inframammary fold distance) were considered during preoperative planning. Surgery was planned according to Tebbetts’ equation, with reference to breast width (ratio of nipple to inframammary fold to breast width equals 0.67).[3] In the sepero-medial pedicle flap, the nipple to inframammary fold distance was measured in the relaxed position, whereas for inferior pedicle reduction, it was measured with maximally stretched skin.

Skin excess was then calculated. Vertical skin excess was easily defined by subtracting the actual measured nipple to inframammary fold distance from the calculated new nipple to inframammary fold distance (according to the new desired nipple position). Horizontal skin excess was identified and marked by slightly pulling and rotating the breast inward and upward, and then outward and downward for the medial and lateral vertical lines, respectively (Fig. 2).

Fig. 2.

Preoperative markings of horizontal skin excess. A, Definition of lateral horizontal skin excess in conjunction with parenchyma volume and position for filling the designed envelope. B, Definition of medial horizontal skin excess in conjunction with parenchyma volume and position for filling the designed envelope.

Skin closure was either performed in a circum-vertical or inverted T pattern. The flap carrying the nipple areolar complex was either superomedial or inferior.

Patients in need of parenchymal excision underwent reduction mammaplasty, whereas those needing parenchymal redistribution underwent mastopexy. Those presenting with marked fibro-adenotic breasts or with a history of heavy chronic smoking in combination with a suprasternal notch to nipple distance ≥ 39 cm were considered for inferior pedicle reduction. Otherwise, superior or superomedial pedicles were considered.

Operative Principles:

All surgeries were performed under general anesthesia with the patient in the supine position. After marking the incisions and new nipple position, the areola was slightly stretched and marked using a cookie cutter that was 4.2 cm in diameter.

Incisions followed the markings, and the decided flap was elevated and secured. The remaining parenchyma was managed based on the decision of performing reduction or mastopexy.

Closure of parenchymal pillars was always achieved via suturing, using Polyglactin 910 2-0 inverted interrupted sutures; moderate tension was applied to merely achieve opposition of the parenchymal flaps to one another. The flaps did not need fixation to the pectoral fascia, and tightness and molding depended on parenchymal flap closure; no barbed sutures were used in this study. The skin was then closed using Polyglactin 910 3-0 for the subcutaneous layers, and Poliglecaprone 25 for the dermis; the dermal and epidermal closures were tension free.

Liposuction was always performed after skin closure to remove excess lateral breast fullness, which leads to the boxy shape; upper back roll was performed when needed.

Revision Cases (Group 1)

Assessment:

A detailed history was obtained, which included the pedicle used for the previous surgery, whenever possible. Revision surgery was performed at a minimum of 1 year after the previous surgery. Waiting for 1 year after surgery helped in achieving final breast settlement and assured safety for selection of the pedicle.

All revision cases in group 1 that presented with boxy breasts were analyzed in detail, as mentioned previously in the primary mammaplasty group. The problem was identified based on the skin measurements obtained and further analysis of the conus distribution, and its management plan was formulated.

This assessment may be performed easily and quickly by using an algorithm, which divides the causes of development of boxy breasts into skin or conus/parenchymal components (Fig. 3).

Fig. 3.

Algorithm for management of a boxy breast. Problem analysis can be divided into two major components (skin and conus); each component is further subdivided and the proposed management may be followed as per the algorithm.

Analysis of the boxy breast started by defining the aesthetically desired new nipple position. The ideal nipple to inframammary fold distance was then checked as suggested by Tebbetts, with reference to breast width.[3] Horizontal skin excess was assessed as previously described. At this point, it was easy to follow the proposed algorithm of the study for correcting the cause of the deformity.

Management:

Problems with nipple-areola complex position were revised by performing circumareolar mastopexy, crescent mastopexy, or redo surgery. Cases presenting with skin envelope problems (such as deficient nipple to inframammary fold distance) were addressed by elliptical excision and closure along the vertical limb. Horizontal skin excess was managed by redo surgery for widening the angle of divergence.

Parenchymal volume and position were simultaneously assessed and defined. Boxy breasts due to conus central deficiency needed pillar recreation and/or lipofilling of central deficiency. Central recreation of pillars and lateral liposuction were performed in cases of lateral excess.

Revision surgeries for boxy breasts can easily be summarized to include those involving skin revision, pillar adjustment or lipomodelling, or a combination of all these.

Postoperative Care:

Dressings were changed after 48 hours, and skin stitches usually absorbed within 3 weeks. Silicon based patches and creams were used for a period of 6 weeks, starting 3 weeks postoperatively. The patients were advised to use a medical bra day and night for 1 month, and then during the day only for another 2 months.

Postoperative Assessment:

Measurements of the breast were taken during follow up at 6 months postoperatively and were compared with the preoperative values. This was performed because boxy breasts cannot be evaluated appropriately until 6 months have elapsed after surgery.

Results were assessed according to patient satisfaction, measured on a scale of one to 10, with one being extremely unsatisfied and 10 extremely satisfied. Variables were evaluated according to a questionnaire that focused on aesthetic rather than on physical results. It included questions regarding surgical satisfaction with breast appearance, sexual wellbeing, and overall body image.[8,9] The surgeon’s satisfaction was also evaluated objectively by combining the presence of complications and postoperative measurements, including the suprasternal notch to nipple and nipple to inframammary fold distance.

RESULTS

The study was performed between December 2016 and November 2019 among 57 patients who were candidates for reduction mammaplasty, mastopexy, or revision mammaplasty following reduction or mastopexy and presenting with boxy breast deformity; 55 completed the 6-month followup period. Patients’ ages ranged from 30 and 59 years, and the average body mass index was 30 (range: 24–33) kg/m2.

Study patients were grouped into two categories:

Group 1: These patients had boxy breasts after reduction mammaplasty or mastopexy (minimum 6 months) and were candidates for revision.

Group 2: These patients were candidates for reduction mammaplasty or mastopexy (they were all primary cases).

Group one included 14 cases; their ages ranged between 33 and 58 years (mean age: 44 years). The average preoperative suprasternal notch to nipple distance was 22.5 cm (SD ±1.2), while the average preoperative nipple to inframammary fold distance was 7.7 cm (SD ±1.8). Postoperative measurements showed an average suprasternal notch to nipple distance of 21.6 cm (SD ±0.7) and an average nipple to inframammary fold distance of 9 cm (SD ±1.4).

Patients in group 1 were analyzed and managed according to the scheme proposed in the study, as follows (Table 1):

Table 1.

Group 1 Patient Characteristics

Patient	Age	Preoperative		Postoperative		Problem Analysis	Management
		SSN/NAC	N/IMF	SSN/NAC	N/IMF
1	35	21	6	21	8	Short N-IMF distance	Elliptical excision + lateral roll liposuction
2	37	21	9	21	10	Short N-IMF distance	Elliptical excision
3	55	19	7	19	9	Short N-IMF distance	Elliptical excision
4	58	22	7	22	10	Short N-IMF distance + central deficiency	Elliptical excision + lipofilling
5	33	22	8	22	8	Lateral fullness	Lateral roll liposuction
6	45	25	7	22	8	Low set nipple, central deficiency, lateral excess	Superior pedicle Wise pattern redo mammaplasty with lateral roll liposuction
7	38	24	5	23	7	Short N-IMF distance, lateral excess	Superior pedicle Wise pattern redo mammaplasty and lateral roll liposuction
8	48	27	7	23	8	Low set NAC, central deficient skin and conus.	Superior pedicle Wise pattern redo mammaplasty with lateral pillar liposuction
9	42	21	8	21	8	Excess lateral breast roll	Liposuction
10	37	23	7	22	10	Excess lateral roll, shortened N-IMF distance with central deficiency	Superior pedicle Wise pattern redo mammaplasty with recreation of pillars as well as lateral roll liposuction
11	39	21	6	21	8	Short N-IMF distance +lateral fullness	elliptical excision + lateral liposuction
12	51	24	10	22	10	Low set NAC	Circumareolar mastopexy
13	52	23	8	21	10	Low set NAC excess horizontal skin and shortened N-IMF distance	Superior pedicle Wise pattern redo mammaplasty with recreation of pillars
14	46	22	11	22	12	Central deficiency	Lipofilling

Skin envelope problems:

Low set nipples were managed by circumareolar skin mastopexy.

Deficient nipple to inframammary fold distances in relation to given breast width were elongated by elliptical excision and closure.

Horizontal skin excess was managed by widening the angle of divergence by creating new pillars (superficial pillars being skin only).

Conus problems:

Deficient central portions were managed by lipofilling or recreation of pillars.

Excess lateral portions were managed by liposuction of the lateral breast and/or recreation of pillars.

None of the patients in group 1 needed revision surgeries. Two patients complained of superficial partial wound infection, one of whom suffered partial areolar necrosis. Both patients were managed by repeat dressings and antibiotic ointments for 10 days.

Patient satisfaction was measured on a scale of one to 10, with one being extremely dissatisfied and 10 being extremely satisfied. The scores indicated overall satisfaction, with an average score of 9.5; based on the postoperative measurements and complication rate, the objective surgeon’s satisfaction in this group was 8.2. Two example cases of group 1 patients showing breast boxing correction with their pre and postoperative pictures were shown in Supplemental Digital Contents 1 and 2. (See figure 1, Supplemental Digital Content 1, which displays (a) preoperative photograph of a patient (case 3) seeking revision surgery for correction of boxy breast appearance and scarred breast, with a history of complicated breast reduction surgery 13 months previously. (b) postoperative photograph of case 3 taken 2 weeks postoperatively. ) (See figure 2, Supplemental Digital Content 2, which displays (a) preoperative photograph of a patient (case 4) seeking revision surgery for correction of boxy breast appearance, with a history of breast reduction surgery 12 months previously. (b) postoperative photograph of case 4 taken 1 month postoperatively (edema and slight postoperative boxiness have persisted; these improved during follow-up after edema had settled). .)

The 37 patients in group 2 had a mean age of 44 (range: 30–59) years. Among the 37 patients, 26 underwent reduction mammoplasty; most of them underwent superomedial breast reduction. However, four patients needed an inferior pedicle based on their preoperative suprasternal notch to nipple distance. The remaining 11 underwent mastopexy; all had a superomedial pedicle, and upper pole fullness was achieved using a septum-based flap allowing for auto-augmentation of the reduced skin envelope (Fig. 4).

Fig. 4.

Skin pattern design in groups 1 and 2.

The average preoperative suprasternal notch to nipple distance in group 2 was 33.7 cm (SD ±5), while the average preoperative nipple to inframammary fold distance was 14.8 cm (SD ±2.2). The average postoperative suprasternal notch to nipple distance was 21.9 cm (SD ±0.8), and the average postoperative nipple to inframammary fold distance was 8.7 cm (SD ±1.2). (Tables 2, 3)

Table 2.

Patient Characteristics in Group 2 (Reduction Cases)

Group 2 (Reduction Cases)
	SSN-N		N-IMF
Age (y)	Preoperative	Postoperative	Preoperative	Postoperative	Reduced Volume gr.
40	38	22	15	10	220
40	44	22	13	9	370
44	24	21	20	10	150
56	35	23	16	9	410
51	36	22	14	9	340
50	38	21	11	9	270
47	38	21	13	7	380
44	34	23	12	7	320
37	37	22	13	7	440
41	41	23	12	8	560
35	32	22	16	8	270
40	35	23	14	9	350
37	44	23	13	10	520
34	38	21	17	9	330
57	32	22	16	10	460
45	24	21	13	10	160
38	36	22	20	7	360
41	31	22	16	10	280
54	29	22	14	8	340
55	46	23	16	10	540
50	44	22	18	7	630
43	26	22	12	7	210
47	36	21	15	8	350
32	32	22	15	8	320
34	37	24	17	10	470
43	36	22	14	10	310

Table 3.

Patients Characteristics in Group 2 (Mastopexy Group)

Group 2 (Mastopexy Cases)
	Preoperative		Postoperative
Age	SSN-N		N-IMF
39	24	14	21	8
45	25	17	22	10
36	36	15	21	9
30	34	12	22	10
54	31	14	22	8
35	32	19	21	7
43	23	13	21	9
52	30	14	21	7
51	35	16	21	10
45	25	13	22	9
59	33	15	21	9

One patient presented with bottoming, which required revision surgery by transverse excision of the skin only under local anesthesia. The second patient complained of upper pole hollowness, which was corrected by lipofilling.

Two example cases of group 2 patients showing breast boxing prevention results during reduction mammaplasty and mastopexy with their pre and postoperative pictures were shown in Supplemental Digital Contents 3 and 4. (See figure 3, Supplemental Digital Content 3, which displays (a) the preoperative photograph of a patient seeking reduction/mastopexy (case 1) with horizontal and vertical skin excess. (b) the postoperative photograph of case 1 taken 3 months postoperatively .) (See figure 4, Supplemental Digital Content 4, which displays (a) the preoperative photograph of a patient seeking mastopexy (case 2), with horizontal and vertical skin excess. (b) postoperative photograph of case 2 taken 6 months postoperatively. .)

Patient satisfaction measured on a scale of one to 10 indicated overall satisfaction, with an average score of 9.1. However, the score for surgeon’s satisfaction was 8.6, and was based on postoperative measurements and the complication rate.

DISCUSSION

The algorithm proposed in the current study (in reference to Blondeel and Tebbets design of N-IMF distance) indicates that preoperative markings, intraoperative techniques, and postoperative orientation may help achieve optimal results and prevent undesired boxing among other types of deformity or asymmetry. Applying a flexible and simplified algorithm provided a more objective plan that enabled surgeons to attain more satisfactory results. Following a preset quantified plan supported and shortened learning curves, and objectively addressed the common postoperative complication, breast boxing.

The number of cosmetic surgeries being performed has increased significantly worldwide. Demands can be realistic in some patients and unachievable in others. Malpractice claims have become increasingly common with breast surgeries, and are particularly relevant to reduction mammaplasty.[1,10] Disfigurements and subsequent need for revision procedures are the most common allegations mentioned in malpractice claims.[11]

In 2017, Winter et al used the Clavien-Dindo classification[12,13] system to analyze the wide range of postoperative complication rates for reduction mammaplasty (4%–54%), that was found in literature. The majority of the cases involved minor complications, and cases with major complications that required revision did not exceed 10%; these were mainly due to shape-related deformities,[14] including malposition of the nipple-areola complex, areolar shape irregularities, hypertrophic circumareolar scars, lower pole aesthetic problems (bottoming out and boxing), pre-sternal webbing, and lateral dog ears.

Bottoming out and boxing of the breast (collectively known as lower pole aesthetic problems) were not discussed objectively till Hidalgo described the boxy shape, which was attributed to either excessive glandular tissue lateral to the pillars or excess skin in the horizontal direction. Tebbets considered the ratio of the nipple to inframammary fold distance to breast width to be the key for assessment of lower pole aesthetic mishaps. Increased ratios denote bottoming, whereas decreased values denote boxing.[2,3,6]

Blondeel et al introduced a system for describing the breast that divided the breast into three components, namely the footprint, conus, and envelop.[4]

Tebbets suggested a method for calculating an aesthetic N-IMF distance, hence an algorithm for skin envelope reduction according to vertical skin excess for reduction mammaplasty. This enabled better fit of the resultant breast envelop to the inner conus without undue tension over the skin wounds.[3,6]

In our practice, some cases are referred after reduction or mastopexy; these patients are unhappy with their breast contour; the complaints were vague and subjective. A trial to analyze the lower pole in view of the Blondeel system[4] found that the lower pole is composed of the conus covered by skin envelope, lying over the lower part of the breast footprint.

This may be caused by poor markings and/or failure to achieve adequate resection and tissue debulking, inability to achieve proper tissue support and stability, or a combination of both. It is imperative to consider lower pole aesthetics while planning surgery; this allows for appropriate analysis of the etiology responsible for the boxy appearance in cases presenting for revision.

Boxy breasts were commonly found after reduction or mastopexy in the first 6 months. After that, when the breast settles down, the problem usually resolves spontaneously. In cases where it persists, it is a complication rather than a sequel.

In practice, the aesthetic appearance of the lower pole of the breasts should be described well in the initial stages. This is classically defined as a biconical shape with the longest axis lying centrally, represented by the nipple to inframammary fold distance; this slants both medially and laterally over the ideal breast footprint[15] (Figs. 5, 6).

Fig. 5.

Illustration of the left breast, which is biconical in shape with its base coinciding with the breast meridian (two slanting cones, with the tips toward the nipple laterally and medially).

Fig. 6.

Illustration in reference to Mallucci et al (2012) of a three-quarter profile view, with an upper pole to lower pole ratio of 45:55.[5]

In the current study, the analysis system relied on the appropriate aesthetic location of the transverse meridian passing through the nipple point, which constitutes the base of the lower pole. The vertical longest axis of the lower pole is the nipple to inframammary fold distance; it then slants laterally and medially with the breast contour.

The new nipple location is of paramount importance while planning for reduction mammaplasty or mastopexy. It should be immediately outside the breast vertical meridian; however, its location in relation to the meridian has been described variably. Classically, it was described in relation to the suprasternal notch or mid-arm line. Tebbetts considered these points as misleading, as they are not on the breast. He suggested that the Pitanguy point is the most accurate, as it is related to the breast itself. Findley however criticized the use of the Pitanguy point for locating the new nipple in low breasted women or those with tuberous breasts, and used the upper breast border as a reference for the nipple point.[3,15,16]

In the current study, the Pitanguy point was used as an indicator for the neo-nipple, as cases post massive weight loss or with congenital breast contour deformities were excluded.

Regarding the lower pole skin envelop, the nipple to inframammary fold distance was described by Malluci in reference to breast vertical height; however, Tebbets described this in relation to breast width. The current study used the definition proposed by Tebbets, which is more convenient for use in patients undergoing reduction surgery; this is in contrast to that used by Malluci for cases undergoing augmentation.[3,5,6]

In his studies, Tebbets quantified skin excess into vertical and horizontal elements.[3,6] The vertical skin excess was calculated, and the pattern of skin excision was determined accordingly. However, the horizontal skin excess was calculated according to the length of the transverse scar; the parenchyma was adjusted according to the designed envelop. In contrast, the skin envelop was adjusted to the available parenchyma in our study, depending on the angle of divergence in our template design. This allowed for more free reduction without compromising nipple areolar complex vitality.

Classically, slanting of the vertical axis in the lateral breast is achieved using two factors: gathering the breast centrally using the pillars concept, and mandatory liposuction laterally for delineating the breast contour.[17] Lateral contouring of the breast using liposuction is of great help for producing more aesthetic and less boxy breasts following reduction. All cases in our study underwent lateral liposuction to prevent contour deformities on long term follow up.

Pillars described by Lassus then by Lejour for vertical mammaplasty were meant to constrict the breast base, thereby providing better contour.[18] However, this concept may be applied for either vertical reductions or inverted T reductions. This step was performed for all reductions or mastopexies in our study. On using the previous mentioned strategies for planning, marking, and performing reduction, the resultant breasts in study group 2 did not show any boxing, either subjectively using the patient questionnaire or objectively based on postoperative parameters or need for revisions.

In the current study, all patients in group 1 underwent reduction or mastopexy at least 1 year before referral. They all complained of contour deformities, either unilateral or bilateral. After applying the Blondeel system of analysis[4] with modifications for the lower pole, and considering the appropriate neo-nipple location, all revision cases had improper nipple location, skin component problems, or conus problems.

Correcting improper nipple location is much easier in boxing than in bottoming.[19] It can be performed by translocating the nipple to a higher position, usually by a few centimeters. This was achieved in the current study via a circumareolar incision or crescent mastopexy.

The skin component problems were all related to a lack of proper evaluation of the vertical and/or horizontal skin excess. These problems either resulted from a short nipple to inframammary fold distance, which was corrected simply by elliptical excision and primary closure for lengthening the distance, or from excessive vertical skin; the latter was corrected simply by widening the angle of divergence and recreating the superficial pillars.

Using the same approach, conus problems may be classified as cases with central deficiency or lateral excess. Lipofilling or recreation of pillars may solve the problem centrally. Lateral excess can be managed by liposuction to the lateral breast roll, in conjunction with recreation of pillars that are gathered centrally.

CONCLUSIONS

Applying a flexible and simplified step-by-step algorithm based on previous literature allowed the use of a more objective plan, that enabled surgeons to attain more satisfactory results. Following a preset quantified plan supported and shortened learning curves, and objectively addressed a common postoperative complication, namely breast boxing. This approach was based on primary analysis of the problem, and allowed the use of the same quantifiable measurements to analyze the problem in patients presenting with boxing; the underlying etiology was therefore identified, and an appropriate guided plan of management was devised.

In conclusion, breast revision surgeries for correction of boxing depend on skin envelope revision, pillar fixation, and lipomodelling (by either lipofilling or liposuction, or a combination of both). Breast boxing may be preventable if a systematic approach is used to plan the operative design. Therefore, understanding the problem and its leading causes may aid in its prevention. Further large-scale prospective studies are needed to validate our findings.